When I was a student, a trauma surgeon described how, in the early days of transplants, he had to physically restrain the transplant surgeons from “harvesting” the kidneys of potential donors. So enthusiastic were surgeons about this exhilarating technology that they were willing to sacrifice one life for another, for they tended to count a life saved by transplant as being of more than ordinary value, perhaps double; and, no doubt irrationally, I have remained mildly suspicious of them, the transplant surgeons, ever since.
There were two opposing articles in a recent edition of the New England Journal of Medicine about the ethics of transplantation. For a number of years the supply of organs for transplant has not equalled the demand, and one way of meeting it would be to relax slightly the rules governing the removal of transplantable organs from donors. At the moment the dead-donor rule (known as the DDR — an acronym that for me still brings first to mind the German Democratic Republic) prevails, according to which the donation of an organ must not kill the donor.
One of the authors suggests that the DDR is routinely violated in any case and that, in so far as it is obeyed, it limits the number of organs available for transplant and thereby allows people to die who could have been saved. But, says the author, “it is not obvious why certain living patients, such as those who are near death but on life support, should not be allowed to donate their organs, if doing so would benefit others and be consistent with their own interests. … Allegiance to the DDR … limits the procurement of transplantable organs by denying some patients the option to donate in situations in which death is imminent and donation is desired.”
Sir Winston Churchill was an inveterate enemy to all physical exertion that went by the name of exercise. He attributed his productivity in life to his physical indolence and once gave the advice that you should never stand when you can sit and never sit when you can lie. He did much of his work in bed.
Modern medicine is decisively against him in his opposition to exercise. Reading the introduction to a paper in a recent edition of the British Medical Journal, you might be forgiven for concluding that the panacea has at long last been found, and that it is exercise. People who are physically active live longer and suffer less from heart disease, strokes, cancer, and diabetes than do the sedentary. They do better in the hospital; and physical inactivity has been estimated to be the fifth most serious contributor to the disease burden of Europe.
The authors of this paper attempted to find out whether exercise is as effective as drugs in reducing mortality in a variety of conditions such as diabetes, stroke, coronary artery disease, and heart failure. They did no actual trial themselves, but rather performed a meta-analysis of the meta-analyses of all the trials that have been published and are relevant to this question: in other words their paper is what might be called a meta-meta-analysis.
Exercise has rarely been compared directly with drug treatments; the authors had therefore mainly to compare the published statistical effect of exercise (compared with no exercise) with that of medication of various sorts (compared with placebo or other medicines). They analyzed the results of 16 meta-analyses which were based upon a total of 254 trials, 54 of them on the effects of exercise and 248 of them on the effects of drugs, involving 339,274 patients in all.
In short they found that the only statistically significant differences in mortality were in stroke and in heart failure. Drugs (diuretics) were superior to exercise in the latter, and exercise to drug treatment in the former. Otherwise there was no difference between drug treatment and exercise.
Diseases that have no objective tests to distinguish them from normality have a tendency to spread like fungus: for example, it is years since I heard anyone say that he was unhappy rather than depressed, and it cannot be a coincidence that 10 percent of the populations of most western countries are now taking antidepressants. Yet the state of melancholia undoubtedly exists, as anyone who has seen a case will attest.
Likewise with autism. I remember an isolated, friendless and uncommunicative patient who tried to kill himself when his landlord could no longer tolerate the collection of light bulbs that he had collected since childhood, was constantly enlarging, and that now threatened to fill the whole house. For the patient light bulbs were the meaning of life. It was difficult to believe in such a case that there was not something biologically wrong with the patient, even if one could find it.
An editorial in the New England Journal of Medicine traces the convoluted history of the diagnosis of autism and Asperger’s syndrome. The pediatricians Leo Kanner and Hans Asperger described the conditions in 1943 and 1944, respectively.
Kanner thought that two features were essential to autism, a psychological separation from the world manifest very early in a child’s life and an obsessive desire to prevent change in the person’s immediate surroundings. Kanner thought that such children had similar parents, often of high intelligence but who were better and happier with ideas than with human relationships. This gave rise later to the concept of the “refrigerator mother,” that is to say a cold and uncommunicative woman who did not cuddle her child or provide it with any emotional warmth, and whose conduct caused the child, by a mechanism of defense, to withdraw into its own world. This was also the era of the “schizophrenogenic” mother, the mother who communicated two messages in one verbal utterance, leaving the child uncertain as to what was meant.
These theories have now been abandoned; they were not only wrong but cruel, for they blamed the mother for the child’s devastating condition. Biology is back in fashion.
Like politicians, doctors are inclined to believe that doing something (especially when it is them doing it) is better than doing nothing. They mistake benevolent intentions for good results, believing that the first guarantee the second. How can philanthropy go wrong?
Besides, doing something stimulates the economy in a way that doing nothing cannot possibly match. If people did only what was necessary, or what was good for them, or what was right, the whole of our economy would soon collapse.
Be that as it may, and for whatever reason, clinical trials that have positive results are more likely to be published than those with negative results. Thanks to several well-publicized scandals, this publication bias, as it is called, is on the decline. GlaxoSmithKline, one of the largest pharmaceutical companies in the world, has promised that henceforth it will publish the results even of trials that are unfavorable to their products as well as those that are favorable.
A paper by Danish researchers just published in the British Medical Journal assesses the extent to which published reports of trials of screening procedures, such as mammography, colonoscopy, PSA-levels, etc., report their harmful effects and consequences as well as their positive ones.
This is particularly important ethically because screening reverses the usual relationship between patient and health-care system. In screening it is the health-care system that initiates the contact, not the other way round. Screening is offered to healthy people, or at least to those complaining of nothing; moreover, the chances of benefit from screening are often slight and those who do benefit from them do so in a sense at the expense of those who are harmed by them. The moral imperative to know the harms of screening is therefore great.
Not long ago the New England Journal of Medicine ran an article on the vexed question of physician-assisted suicide in the case of the terminally ill, and doctors were asked to vote, for or against, online. The results of the poll have just been published.
As the editors are at pains to point out, such a poll has no scientific validity, since those who took the trouble to vote were not a representative sample of anyone but themselves. This does not mean, though, that the poll was altogether without interest, though certain data would have made it even more interesting.
In all, the journal received 5,205 votes from doctors around the world. However, the editors noticed that there were multiple votes in quick succession from several locations in Canada, suggesting a concerted effort to influence the result. These – 1,137 of them – were excluded from the report, leaving 4,068 votes deemed valid.
It would have been interesting to know in which direction the discounted votes voted, but this information was not given. Do those against or those in favor of physician-assisted suicide have a more active lobby or pressure group in Canada? I am not sure I would know which way to bet: one could almost hold a poll on the subject.
Sometimes a single phrase is enough to expose a tissue of lies, and such a phrase was used in a recent editorial in The Lancet titled “The lethal burden of drug overdose.” It praised the Obama administration’s drug policy for recognizing “the futility of a punitive approach, addressing drug addiction, instead, as any other chronic illness.” The canary in the coal mine here is “any other chronic illness.”
The punitive approach may or may not be futile. It certainly works in Singapore, if by working we mean a consequent low rate of drug use; but Singapore is a small city state with very few points of entry that can hardly be a model for larger polities. It also seems to work in Sweden, which had the most punitive approach in Europe and the lowest drug use; but the latter may also be for reasons other than the punishment of drug takers. In most countries (unlike Sweden) consumption is not illegal, only possession. That is why there were often a number of patients in my hospital who had swallowed large quantities of heroin or cocaine when arrest by the police seemed imminent or inevitable. Once the drug was safely in their bodies (that is to say, safely in the legal, not the medical, sense), they could not be accused of any drug offense. Therefore, the “punitive approach” has not been tried with determination or consistency in the vast majority of countries; like Christianity according to G. K. Chesterton, it has not been tried and found wanting, it has been found difficult and left untried.
But the tissue of lies is implicit in the phrase “as any other chronic illness.” Addiction is not a chronic illness in the sense that, say, rheumatoid arthritis is a chronic illness. If it were, Mao Tse-Tung’s policy of threatening to shoot addicts who did not give up drugs would not have worked; but it did. Nor would thousands of American servicemen returning from Vietnam where they had addicted themselves to heroin simply have stopped when they returned home; but they did. Nor can one easily imagine an organization called Arthritics Anonymous whose members attend weekly meetings and stand up and say, “My name is Bill, and I’m an arthritic.”
Most doctors fall into one of two categories: the smaller, who are excessively concerned with their health and regard each bodily sensation as the harbinger of serious disease, and the larger, who neglect it and ignore their symptoms altogether.
I belong to the latter. When I was a young man, for instance, I failed to recognise the symptoms of pneumonia and ignored them until I could hardly breathe. For me, doctors treated illness; they did not suffer from it themselves.
Even more difficult for many doctors is illness among their close relatives. How far should they interfere with diagnosis and treatment, at the risk of antagonising their colleagues? If they interfere, they might be regarded as difficult and obstructive; if they do not, they may overlook serious and even life-threatening mistakes.
A doctor recounts her experience in a recent edition of the New England Journal of Medicine. Her aged father collapsed at home while she happened to be there; he had recently had a quadruple bypass operation. His blood pressure had fallen dramatically.
At the hospital he was diagnosed with dehydration and given intravenous fluids. For a time his blood pressure improved and he felt better. Then his blood pressure dropped again. His daughter called a nurse who increased the fluids and for some reason switched off the alarm of the blood pressure monitor. Then she left.
When her father’s blood pressure dropped yet again, his doctor daughter went to the nursing station to inform the medical team. There she was more or less cold-shouldered, and because she did not want to appear one of those “difficult” relatives who seem to think that their loved one is the only patient the hospital has to look after, she did not insist. After all, doctors and nurses have many subtle or unconscious (and sometimes not so subtle or unconscious) ways of wreaking revenge on those whom they consider to have caused them unnecessary grief.
The medical team had overlooked one of the most obvious causes of loss of blood pressure in this case, namely internal haemorrhage. The patient was on anticoagulants after his cardiac surgery, and such a complication is not uncommon. His daughter decided to examine him herself by means of a rectal examination and found that he was indeed bleeding intestinally.
Schopenhauer would have enjoyed the spectacle of grand rounds in academic hospitals: his theory that people argue for victory more than for truth would have found confirmation there.
In grand rounds a physician presents a complex or enigmatic case to the other physicians of the hospital, who then discuss it in detail. The ostensible purpose is to teach, learn and sometimes to enquire; but such human desires as to show off, to appear more-learned-than-thou, and to appear brilliant are often much in evidence. I once worked in a hospital where an ancient and celebrated physician, who had had more diseases, albeit rare and obscure ones, named after him than any other physician in history, attended such rounds until well into his nineties. Once he had spoken he would ostentatiously turn off his hearing aid, the entire matter having been settled to his satisfaction by his own opinion.
The New England Journal of Medicine carries each week a case report from the Massachusetts General Hospital, presented on a grand round. Generally speaking they record a triumph of diagnosis and often of treatment, somewhat like a Sherlock Holmes story. The more obscure the diagnosis the more brilliant appears the solution, seemingly reached effortlessly by the teamwork of clinicians and pathologists. One cannot help but wonder, sometimes, what has been left out. Certainly the patient’s experience doesn’t get much of a look in.
Recently there was a case reported in the journal that brought to mind the old saying of Victorian surgeons, “the operation was a success, but the patient died.” It concerned a fifty-three year old woman who suffered from persistent redness of the skin and enlargement of the lymph nodes. She was susceptible to infections for which she had repeatedly been admitted to hospital (not the Massachusetts General) and treated with antibiotics.
Even non-hypochondriacs such as I sometimes worry fleetingly about their health when, having reached a certain age, some of their friends and acquaintances fall foul of a disease, namely (in this case) cancer of the prostate. But my anxiety does not last long and so far I have managed successfully to resist all attempts by my medical colleagues to measure my prostate specific antigen (PSA). I want to have as little to do with doctors as possible, other than socially of course, and there is nothing quite like a high PSA level to provoke doctors’ interference in a man’s life.
Would this interference, though, prolong my life if I allowed it to take place? A recent paper in the New England Journal of Medicine starts optimistically and ends pessimistically. It draws attention to the fact that mortality from prostate cancer has fallen drastically and attributes this to improvement both in early diagnosis of the cancer by means of screening and of treatment once diagnosed.
The body of the paper, however, is less sanguine. First 18,880 elderly men were divided into those who were given finasteride, a drug that was hoped would prevent cancer, and those given placebo. Some years later it was discovered that finasteride did indeed reduce the numbers of patients who developed cancer, in fact by nearly a third.
So far so good: but this is not the end of the story. Unfortunately, prostate cancer is a very variable disease such that, while some men die of it, many more men die with it than of it. And while finasteride seems to have prevented many low-grade cancers, those that would not have killed the men in any case, it seems also to have increased both the number and proportion of the more serious kind.
The major medical journals of the world receive far more papers than they can ever publish, and so it is rather surprising when dull, trivial or bad work appears in them. This must mean either that the editors of the journals, like Homer, sometimes nod, or that the general standard of the work submitted for publication is lower than one might hope or suppose.
A recent paper in the New England Journal of Medicine, entitled “Glucose Levels and Risk of Dementia,” by no fewer than fourteen authors, is a case in point. They repeatedly measured the blood glucose levels of 2067 people aged on average 76 at the start of the study, followed them up for a median length of 6.8 years, and correlated the levels with the patient’s chances of developing dementia.
It was already known that diabetics are at increased risk of developing dementia, not surprisingly in view of the damage that diabetes does to small blood vessels in the brain. But the authors of the paper put forward the hypothesis that higher levels of glucose even in non-diabetics would increase the risk of developing dementia.
They indeed found that non-diabetic patients with a blood sugar level of 115 milligrams per decilitre were more likely to develop dementia than those with a level of 100 milligrams. However, the extra chance, 1.18 times, though statistically significant, was so small that its significance in any other sense must be doubted. Generally speaking, epidemiological surveys which find such small differences are not of much value from the point of view of elucidation of the causation of diseases. If you trawled through a hundred factors – coffee consumption, number of begonias in the garden, subscription to a newspaper, etc. – you would probably find five such factors with odds rations as large (or small).
For most of my life I have had no difficulty in sleeping, rather in staying awake. But whether because of a physiological ageing process, or of a guilty conscience aware of a life of cumulative sin, I now experience periods of insomnia. Occasionally I do what I once swore as a young man never to do: I take sleeping tablets.
My favourite, to the exclusion of all others, is Zolpidem (Ambien). It does not leave me feeling groggy, as do other hypnotics, but rather as near to daisy-freshness as I ever feel early in the morning. Imagine my alarm, then, when I saw an article in a recent New England Journal of Medicine that suggested that the drug of my choice might make me a dangerous driver the following day.
Zolpidem is short-acting, which means that it is metabolised and cleared from the body quickly. Some people therefore find that they wake in the middle of the night when they have taken it (previous studies suggest that Zolpidem’s main advantage over placebo is in getting people off to sleep quickly). Having woken in the night, and finding difficulty in returning to sleep, some people are tempted to take more of the drug. Indeed, the manufacturers – the largest company listed on the French stock exchange – have thoughtfully manufactured a lower-dose pill for precisely this situation.
But simulated driving tests done on people after they have woken in the morning having taken Zolpidem demonstrate that they perform less well than people who have taken nothing. This is so even when people claim to feel no after-effects of the drug at all: in other words, they are not the best judges of whether or not they suffer such after-effects. The commonly-heard refrain, principally from middle-class hypochondriacs, that “I know my body” is not true in all, perhaps in many circumstances.
However, the article does not address certain important questions concerning the effect on Zolpidem on driving the following day. The first is that while Zolpidem may reduce performance on simulated driving tests, it is known that insomnia itself does likewise. So the question is not whether Zolpidem affects driving tests, but whether it affects driving tests among those who suffer from insomnia and who take it. In such circumstances, it is conceivable that it improves performance.
When doctors knew nothing and could do even less (if actively harming patients with their treatment counts as doing less than nothing), they hid their ignorance and therapeutic impotence by the use of impressive-sounding Latin terminology. Even when they spoke in the vernacular, they did their best to be incomprehensible, and generally succeeded. Portentousness was then a substitute for prowess.
Doctors are still inclined to use impressive-sounding words for the same purpose: or at any rate, so their critics say. Idiopathic is a learned way of saying that the cause of a disease is unknown; and when a disease is said to be multifactorial in causation, it is an implicit avowal of ignorance: for diseases should at least have necessary causes if doctors can claim to understand them.
Actually, most diseases are multifactorial: necessary conditions of causation in medicine are common, while sufficient conditions are rare. For example, the presence of the tubercle bacillus is a necessary condition for the development of tuberculosis, but not sufficient. Many are the people who are infected who do not get the disease.
An ill-understood condition that is thought nevertheless to be bacterial in origin is noma, or cancrum oris. This is a horrible disease that starts as an infected gum and then eats away a large part of the face, killing the patient or leaving him deformed for life. It now affects mainly children in Africa, but it once occurred in Europe and America and was common in the victims of German concentration camps during the Second World War.
Its cause is unknown, unless extreme poverty and malnutrition can be accepted as causes. Nevertheless, these are an insufficient explanation of the disease because, even in severely impoverished conditions, most people do not get it.
A Swiss group, working in a confined area of Niger, a Sahelian country that was once a French colony and that supplies the uranium from which France generates three quarters of its electricity, tried to find the cause of noma, that is to say a bacterially necessary precondition for its development, by comparing 82 children who suffered from it with over 300 matched control who did not. In summary, they failed to do so as have others before them, though certainly not for lack of trying. Their report of their efforts appears in a recent edition of The Lancet.
In private health-care systems, rationing of health care is by price; in public health care it is by waiting lists and administrative fiat. Both have their defenders, usually ferocious and bitterly opposed, but the fact remains that there are some treatments that have to be rationed however much money is available for health care: as when, for example, there are more people needing organ transplants than there are organs to be transplanted. Few people would be entirely happy to allocate organs merely to the highest bidder.
A recent article in the New England Journal of Medicine tackles the problem of allocation of lung transplants. A system was in place in the United States that excluded children under 12 years of age from receiving adult lungs as transplants, an exclusion that parents of a child with cystic fibrosis challenged in the courts. The problem for children under the age of 12 requiring lung transplants is that there are very few child donors, so in effect the system discriminated against them.
The reason for the exclusion was that most children for whom lung transplants are considered have cystic fibrosis, a condition for which the results of such transplants are equivocal given the constantly improving medical treatment of the disease. Moreover, children are especially liable to complications from the procedure, though these can be partially overcome by using not whole adult lungs for transplant but only resected lobes of them.
The American system of allocation of lungs for transplant into adults takes into account various factors, such as years of potential benefit from transplant, the imminence of death without transplant, the statistical chance of success of transplant, and so forth. Ability to pay does not come into it; in other words it is a socialized system, but there is a mechanism of appeal for those relegated to low priority which the more educated and wealthier are better able to take advantage of. No explicit judgment is made about the relative social or economic worth of the individual, however, for that way madness, or at least extreme nastiness, lies. And the authors of the article think that, on the whole, the system works well, for it seems to stand to reason that those who would benefit most should go to the top of the waiting list.
I once had a small transplant dilemma of my own…
Doctors are often appalled by their patients’ unhealthy habits, as much for aesthetic as for health reasons. They are also irritated by the refractory nature of those habits and the failure of patients to do anything about them even when repeatedly advised to do so. Such repetition serves a purpose, however. Doctors may not be able to cure their patients, but they can at least make them feel guilty. To do so relieves the doctor’s feelings.
Now that Type II diabetes – that used to be called maturity-onset in the days before children began to get it – has reached epidemic proportions, the scope for medical lifestyle badgering has increased enormously. But does it do any good?
The results of a very prolonged trial in America have just been published in the New England Journal of Medicine. More than 5000 fat Type II diabetics aged between 45 and 75 were randomly allocated to normal treatment and standard advice, on the one hand, and (sinister phrase) “intensive lifestyle intervention” on the other. The investigators ended the trial after most patients had participated in it for about ten years. Something called “futility analysis” revealed that prolongation of the trial was unlikely to produce positive results.
There is more rejoicing in the chambers of malpractice lawyers over one missed diagnosis than over ninety-nine dangerous, unnecessary and expensive investigations. It is therefore unsurprising that doctors are particularly anxious not to miss pulmonary embolus, a clot in the pulmonary arteries, which has been called a silent killer. There are several factors that predispose to PE, as it is known, among them age, a recent operation or having sat for a long time in a confined space. A friend of mine collapsed with a PE at home one day, and it was then that his polycythaemia rubra vera, a chronic overproduction of red cells, was diagnosed.
If PE can kill you, and if there is an effective treatment, it might seem that an improvement in the ability to detect it is to be welcomed. But, as is often the case in medicine, matters are a little more complex than they seem. As a recent article in the British Medical Journal put it:
If all pulmonary emboli caused important harm or death if untreated, finding more small clots would be an unqualified advance. However, there is evidence that some small clots do not need treatment…
And while new technology allows more small clots to be detected that would not have been detected by older methods, it does not give any guidance as to which of them should be treated. Since treatment (with anticoagulants) is itself not without risk, it is possible that the increased detection of small clots does more harm than good.
In the 8 years after the introduction of a new technique called multidetector CT pulmonary angiography, the rate of pulmonary embolus in the U.S. rose by 80 percent, from 62.1 to 112.3 per 100,000 adults. Part of the problem was that the new equipment, being very expensive to install, had to be used to justify its purchase. The result was many more PEs.
Treatment made no great advances in those years, and the overall rate of death from PE in the United States remained more of less constant. However, the fatality rate of detected PEs fell greatly, from 12.3 to 7.8 percent, suggesting that most of the PEs that were now being detected that would not previously have been detected were harmless.
Shakespeare, on the whole, was in favor of sleep – at least if the opinions of his characters are any guide to his own opinion. “He that sleeps feels not the toothache,” says the Gaoler in Cymbeline. Sleep, says Macbeth:
… knits up the ravell’d sleave of care
The death of each day’s life, sore labour’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
By contrast, not to sleep is a torment. Shakespeare must have known insomnia, for in Sonnet XXVII he says:
Weary with toil, I haste me to my bed…
But then begins the journey in my head…
And keeps my drooping eyelids open wide,
Looking on darkness which the blind do see.
Shakespeare also knew that “there’s meaning in thy snores,” though perhaps not the meaning that doctors now attach to them. They often mean obstructive sleep apnea (OSA), when sleep, which should be “death’s counterfeit,” becomes death’s possible harbinger, in the form of heart attacks and strokes.
According to a recent article in the New England Journal of Medicine, between a fifth and a quarter of the American population suffer from OSA, and this poses a risk, whose magnitude is not precisely known, to patients undergoing surgical procedures. The reason the magnitude is not precisely known is that it is difficult to control for obesity: not all people who are fat have OSA, and not all people who have OSA are fat, but there is a strong correlation, almost certainly a causative one. What the authors of the article call “the epidemic” of OSA – yet another epidemic of a non-contagious risk factor – is really an “epidemic” of obesity. A higher proportion of patients undergoing surgery than in the rest of the population have OSA: not surprisingly, 80 percent of patients being operated on for their obesity have it. All in all, perhaps 10 million operations are performed in America annually on people with OSA.
Resistance to antibiotics is often described by neo-pagans as Mother Nature’s vengeance on Man for having had the temerity to interfere in her natural biological processes. According to the neo-pagans, this vengeance has left Man (deservedly) worse off than if he had never discovered antibiotics at all. I do not see the logic of this.
There is no doubt, however, that bacterial resistance to antibiotics is a serious problem worldwide. It is particularly serious in hospitals, where patients may pick up infections that they never had before admission. Many patients die from these infections, which may be of epidemic proportions.
The most important such infection is MRSA, methicillin-resistant Staphylococcus aureus. (Methicillin is a semi-artificial penicillin that was developed when the Staphylococcus first became resistant to ordinary penicillin, and soon met with resistance itself.) MRSA accounts for most post-surgical infections; the proportion of patients infected by it is often taken in research as a measure of a hospital’s hygiene.
An important paper in a recent edition of the New England Journal of Medicine compares various strategies for reducing the spread of MRSA in intensive care units, a common place for patients to become infected.
The method of control usually employed is to screen patients for MRSA on admission to the ICU and to institute special precautions such as isolation and barrier nursing if they test positive. The authors compared this method with attempts by means of antibacterial products at “decolonization” of those who tested positive, and similar “decolonization” practiced on every patient admitted to an ICU irrespective of whether or not he tested positive for MRSA.
Everyone who needs an operation (which eventually will include most of us) wants to be assured that it will be carried out in the best and safest conditions possible. All operations are serious for those having them; a minor operation, as the British physician George Pickering once put it, is an operation carried out on someone else.
Most people with the time or ability to search for the best hospitals, surgeons, etc., will not think of considering the day of the week on which the operation will be performed as a factor of safety. It has long been known that emergency operations done at night or on the weekends have worse results than those done during the day on weekdays; but what about routine or planned operations, those (the great majority) that can be done at the surgeon’s and hospital’s leisure, as it were?
A huge statistical study done in Britain and recently published in the British Medical Journal examined the 30 day death rates after all non-emergency operations performed between 2008 and 2011 (except day cases) according to the day on which the procedure was performed.
There were in total 27,582 deaths after 4,133,345 operations, a raw rate of 6.7 per 1000: a figure that by itself would have astonished our forebears, who were used to, and took as inevitable, death rates at least a hundred times higher.
What the researchers found was that people who underwent an operation on Fridays had a death rate 44 percent higher than those who underwent an operation on Mondays, while those who underwent an operation on the weekend had a death rate 82 percent higher.
When I was in my mid-twenties I developed heart failure on a flight to India. It was caused by viral myocarditis, and I found the whole experience interesting rather than alarming because I was still at an age when I thought I could not possibly die. Neither did it occur to me to request medical assistance: I had some insight into the helplessness of doctors in such situations.
A couple of years later I accompanied a madman on a flight back to his own country. His main symptom was a desire to kill himself by jumping out of high windows: not the ideal airline passenger, you might have thought. In my pocket I had a syringe ready with tranquillizer with which to jab him if he became difficult. It was all arranged very casually, but in the event nothing untoward happened.
We are better organized now, of course, as a paper in a recent edition of the New England Journal of Medicine shows. The authors collected data on the medical emergencies that occurred among roughly 10 percent of airline passengers worldwide between January 2008 and October 2010.
It is often said that flying is the safest means of transportation, and it does not seem to be medically very hazardous either. There was one emergency every 604 flights, and one per 62,500 passengers. Moreover, most of the emergencies turned out to be trivial or minor; only 7.3 percent – that is to say, 875 of 11,920 cases – resulted in diversion of the aircraft. Of course, 875 flights is a lot relative to most people’s lifetime, but it was 875 of 7,198,116 flights.
The most common symptom was fainting or feeling faint, followed by breathlessness and then nausea or vomiting. There were 30 deaths on board and 6 shortly after landing. The age of the oldest passenger to have suffered an emergency in flight was 100 (he didn’t die, though, and lived to fly another day).
Sometimes what is not said is more eloquent than what is. The implicit often has a more powerful effect on the imagination than the explicit; as Emily Dickinson put it, “Success in Circuit lies.” A recent article in the New England Journal of Medicine about Hepatitis C was eloquent in its omissions.
Hepatitis C is a virus infection which for many years causes no symptoms but which often goes on to produce chronic liver disease, cirrhosis, and cancer. About 85 percent of people infected with the virus develop chronic liver disease.
The article in the NEJM is titled “Hepatitis C in the United States.” The authors provide an estimate of the number of people infected with the virus: between 3.2 and 3.5 million.
The infection can now be treated so as to prevent its long-term consequences. Unfortunately, the treatment is expensive: about $70,000 per head for a full course, according to the authors. If every person who tested positive for the virus were treated, the cost would therefore be between $224,000,000,000 and $245,000,000,000. That is some stimulus to the economy!
The cost of treatment might come down (or, of course, go up, as new and costlier treatments are discovered). Not everyone who is infected needs treatment. Perhaps a vaccine will be developed and the problem in effect will go away. For the moment, though, we must deal with the silent epidemic – as the assistant secretary for health, Howard Koh, called it – with the tools now available to us.
Simple scientific questions require simple scientific answers; doctors want unequivocal guidance to their practice so that they do not fumble in the dark. But it is easier to ask questions than to answer them, as two papers published in the same week in the New England Journal of Medicine and the Journal of the American Medical Association attest.
The question asked by the two papers was the optimum level of oxygenation in the blood of pre-term infants. In the past it was rather naively supposed that if oxygen were necessary, then more of it must be better; but premature infants who were exposed to high levels of oxygen developed a condition known as retinopathy of prematurity, often leaving them blind or severely impaired visually.
The two trials, one from Britain, Australia and New Zealand, and the other from the United States, Canada, Argentina, Finland, Germany and Israel, sought to establish whether a higher or lower level of oxygen saturation of the blood was better for infants born very prematurely. The results were different, if not quite diametrically opposed.
The first trial found that babies treated so that their blood oxygen saturation was higher had a lower death rate at 36 weeks than those treated so that their levels were lower. 15.9 percent in the high-saturation group died compared with 23.1 per cent in the lower. You would have to treat 14 babies with the high oxygen saturation to save life more than treating them at the lower level.
Not long ago I bought a book, published in 1922, titled Syphilis of the Innocent. Needless to say, the title implied a corollary: for if syphilis could be contracted by the innocent (as, for example, in the congenital form of the disease), it could also be contracted by the guilty.
In general, however, physicians do not inquire after the morals of their patients, except in so far as those morals have immediate pathological consequences. They do not refuse to treat patients because they find them disgusting, because they find them unappealing, because they are appalled by the way they choose to live. They try to treat them as they find them; they may inform, but they do not reprehend.
However, in practice things are sometimes more complex than this ecumenical generosity of spirit might suggest. According to an article in a recent edition of the New England Journal of Medicine, some doctors have been turning away patients on the grounds that they were too fat (one physician suggested that she did so because, ridiculously, she feared for the safety of her staff once the patients weighed more than 200 pounds), or that their children have gone unimmunized. Is such discrimination by physicians legitimate or illegitimate, legally or morally speaking? Is there not a danger that physicians may hide behind pseudo-medical justifications to express their personal prejudices or to coerce patients into doing what the physicians think is good for them?
Does practice really make perfect? Does it even lead to improvement? One feels instinctively that it should, that the more experience a physician has, the better for the patient. Much of the skill of diagnosis is pattern-recognition rather than complex intellectual detection, and it follows that the longer a physician has been at it, the quicker he will recognize what is wrong with his patients. He has experience of more cases than younger doctors to guide him.
But the practice of medicine is more than mere diagnosis. It often requires manual dexterity as well, and the ability to assimilate new information as advances are made. These may decline rather than improve with age. Too young a doctor is inexperienced; too old a doctor is past it.
A recent paper, whose first author comes from the Orwellianly named Department of Veterans’ Affairs Center for Health Equity Research and Promotion, examined the relationship between the years of an obstetrician’s experience and the rate of complications the women under his care experienced during childbirth. The authors examined the records of 6,705,311 deliveries by 5,175 obstetricians in Florida and New York. No one, I think, would criticize the authors for the smallness of their sample.
They examined the rate of serious complications such as infection, haemorrhage, thrombosis, and tear during or after delivery, divided by obstetrician according to his number of years of post-training experience. Reassuringly, and perhaps not surprisingly, experience reduced the number of such complications decade after decade. The rate of complications was 15 percent in the first ten years after residency; it declined by about 2 percent to 13 percent in the first decade thereafter, by about 1 percent in the subsequent decade to 12 percent, and by half a percent in the next. In other words, improvement continued, but less quickly as the obstetricians became more experienced; the authors appear not to have continued their study to the age at which the rate of complications started to rise again (if indeed there is such an age).
There was a time in my country when, among other unpleasant duties, the prison doctor was required to assess prisoners for their fitness for execution. Needless to say, not much attention was paid in medical school to this particular skill: the physician was on his own because in those days there were no such things as official guidelines. The rough and ready rule was that a man was fit to be executed if he knew that he was to be executed and why. It was the death-penalty equivalent of informed consent to surgery.
One of the last British executioners, Albert Pierrepoint, who hanged about 600 people, wrote in his memoirs that he was often asked if people struggled on their way to the gallows. He replied that he had known only one do so; to which he added, by way of explanation, “And he was a foreigner.” However, foreign nationality was not in itself a contraindication to execution. Pierrepoint was one of the executioners at Nuremberg.
An article in a recent edition of the New England Journal of Medicine draws attention to the ethical and practical dilemmas of American physicians asked to assess people for fitness to carry concealed weapons. Again this is not a skill taught in medical schools. No firm criteria, beyond those of common sense (which have not been validated by research), have been laid down. It seems obvious that people with paranoid personalities or psychoses, gross depression or mania, those who take cocaine, amphetamines, or other stimulants, and alcoholics should be refused permission to carry concealed weapons. But many of those conditions (if taking cocaine can properly be called a condition) are easy to conceal or difficult to detect. How far is the doctor to go in attempting to detect them? Interestingly, or curiously, the authors do not mention hair or blood tests, which could certainly help the doctor detect drug and alcohol abuse.